In the normal state of the thoracic organs, the pericardial envelope of the heart is at all times more or less uncovered by the anterior edge of the left lung, as seen in PLATE 22. When serous or other fluid accumulates to an excess in the pericardium, so as considerably to distend this sac, it must happen that a greater area of pericardial surface will be exposed and brought into immediate contact with the thoracic walls on the left side of the sternal median line, to the exclusion of the left lung, which now no longer interposes between the heart and the thorax. At this locality, therefore, a puncture may be made through the thoracic walls, directly into the distended pericardium, for the escape of its fluid contents, if such proceeding be in other respects deemed prudent and advisable.
The abdominal cavity being very frequently the seat of dropsical effusion, when this takes place to any great extent, despite the continued and free use of the medicinal diuretic and the hydragogue cathartic, the surgeon is required to make an opening with the instrumental hydragogue—viz., the trocar and cannula. The proper locality whereat the puncture is to be made so as to avoid any large bloodvessel or other important organ, is at the middle third of the median line, between P the umbilicus, and Z the symphysis pubis. The anatomist chooses this median line as the safest place in which to perform paracentesis abdominis, well knowing the situation of 2, 3, the epigastric vessels, and of Y, the urinary bladder.
All kinds of fluid occupying the cavities of the body gravitate towards the most depending part; and therefore, as in the sitting or standing posture, the fluid of ascites falls upon the line P Z, the propriety of giving the patient this position, and of choosing some point within the line P Z, for the place whereat to make the opening, becomes obvious. In the female, the ovary is frequently the seat of dropsical accumulation to such an extent as to distend the abdomen very considerably. Ovarian dropsy is distinguished from ascites by the particular form and situation of the swelling. In ascites, the abdominal swell is symmetrical, when the body stands or sits erect. In ovarian dropsy, the tumour is greatest on either side of the median line, according as the affected ovary happens to be the right or the left one.
The fluid of ascites and that of the ovarian dropsy affect the position of the abdominal viscera variously In ascites, the fluid gravitates to whichever side the body inclines, and it displaces the moveable viscera towards the opposite side. Therefore, to whichever side the abdominal fluid gravitates, we may expect to find it occupying space between the abdominal parietes and the small intestines. The ovarian tumour is, on the contrary, comparatively fixed to either side of the abdominal median line; and whether it be the right or left ovary that is affected, it permanently displaces the intestines on its own side; and the sac lies in contact with the neighbouring abdominal parietes; nor will the intestines and it change position according to the line of gravitation.
Now, though the above-mentioned circumstances be anatomically true respecting dropsical effusion within the general peritonaeal sac and that of the ovary, there are many urgent reasons for preferring to all other localities the line P Z, as the only proper one for puncturing the abdomen so as to give exit to the fluid. For though the peritonaeal ascites does, according to the position of the patient, gravitate to either side of the abdomen, and displace the moveable viscera on that side, we should recollect that some of these are bound fixedly to one place, and cannot be floated aside by the gravitating fluid. The liver is fixed to the right side, 11, by its suspensory ligaments. The spleen occupies the left side, 12. The caecum and the sigmoid flexure of the colon occupy, R R*, the right and left iliac regions. The colon ranges transversely across the abdomen, at P. The stomach lies transversely between the points, 11, 12. The kidneys, O, occupy the lumbar region. All these organs continue to hold their proper places, to whatever extent the dropsical effusion may take place, and notwithstanding the various inclinations of the body in this or that direction. On this account, therefore, we avoid performing the operation of paracentesis abdominis at any part except the median line, P Z; and as to this place, we prefer it to all others, for the following cogent reasons—viz., the absence of any large artery; the absence of any important viscus; the fact that the contained fluid gravitates in large quantity, and in immediate contact with the abdominal walls anteriorly, and interposes itself between these walls and the small intestines, which float free, and cannot approach the parietes of the abdomen nearer than the length which the mesenteric bond allows.
If the ovarian dropsy form a considerable tumour in the abdomen, it may be readily reached by the trocar and cannula penetrating the line P Z. And thus we avoid the situation of the epigastric vessels. The puncture through the linea alba should never be made below the point, midway between P and Z, lest we wound the urinary bladder, which, when distended, rises considerably above the pubic symphysis.
Amongst the many mechanical obstructions which, by impeding the circulation, give rise to dropsical effusion, are the following:—An aneurismal tumour of the aorta, A, or the innominate artery, [Footnote 1] F, may press upon the veins, H or D, and cause an oedematous swelling of the corresponding side of the face and the right arm. In the same way an aneurism of the aorta, Q, by pressing upon the inferior vena cava, T, may cause oedema of the lower limbs. Serum may accumulate in the pericardium, owing to an obstruction of the cardiac veins, caused by hypertrophy of the substance of the heart; and when from this cause the pericardium becomes much distended with fluid, the pressure of this upon the flaccid auricles and large venous trunks may give rise to general anasarca, to hydrothorax or ascites, either separate or co-existing. Tuberculous deposits in the lungs and scrofulous bronchial glands may cause obstructive pressure on the pulmonary veins, followed by effusion of either pus or serum into the pleural sac. [Footnote 2] An abscess or other tumour of the liver may, by pressing on the vena portae, cause serous effusion into the peritonaeal sac; or by pressure on the inferior vena cava, which is connected with the posterior thick border of the liver, may cause anasarca of the lower limbs. Matter accumulating habitually in the sigmoid flexure of the colon may cause a hydrocele, or a varicocele, by pressing on the spermatic veins of the left side. It is quite true that these two last-named affections appear more frequently on the left side than on the right; and it seems to me much more rational to attribute them to the above-mentioned circumstance than to the fact that the left spermatic veins open, at a disadvantageous right angle, into the left renal vein.
[Footnote 1: The situation of this vessel, its close relation to the pleura, the aorta, the large venous trunks, the vagus and phrenic nerves, and the uncertainty as to its length, or as to whether or not a thyroid or vertebral branch arises from it, are circumstances which render the operation of tying the vessel in cases of aneurism very doubtful as to a successful issue. The operation (so far as I know) has hitherto failed. Anatomical relations, nearly similar to these, prevent, in like manner, an easy access to the iliac arteries, and cause the operator much anxiety as to the issue.]
[Footnote 2: The effusion of fluid into the pleural sac (from whatever cause it may arise) sometimes takes place to a very remarkable extent. I have had opportunities of examining patients, in whom the heart appeared to be completely dislocated, from the left to the right side, owing to the large collection of serous fluid in the left pleural sac. The heart’s pulsations could be felt distinctly under the right nipple. Paracentesis thoracis was performed at the point indicated in PLATE 26. In these cases, and another observed at the Hotel Dieu, the heart and lung, in consequence of the extensive adhesions which they contracted in their abnormal position, did not immediately resume their proper situation when the fluid was withdrawn from the chest. Nor is it to be expected that they should ever return to their normal character and position, when the disease which caused their displacement has been of long standing.]